Ebook Dx/Rx: Sexual dysfunction in men and women – Part 1

(BQ) Part 1 book “Dx/Rx: Sexual dysfunction in men and women” has contents: Physiology of erection, pathophysiology of erectile dysfunction, physical diagnosis and testing, medical therapies for erectile dysfunction, surgical treatments for erectile dysfunction,… and other contents.

Dx/Rx: Sexual Dysfunction in Men and Women Edited by Stanley Zaslau, MD, MBA, FACS Professor Urology Residency Program Director Division of Urology West Virginia University Morgantown, West Virginia 71966_00_FM_pgs_00i-00x_Zaslau.indd i 8/31/10 9:35 AM World Headquarters Jones & Bartlett Learning 40 Tall Pine Drive Sudbury, MA 01776 978-443-5000 info@jblearning.com www.jblearning.com Jones & Bartlett Learning Canada 6339 Ormindale Way Mississauga, Ontario L5V 1J2 Canada Jones & Bartlett Learning International Barb House, Barb Mews London W6 7PA United Kingdom Jones & Bartlett Learning books and products are available through most bookstores and online booksellers To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com Copyright © 2011 by Jones & Bartlett Learning, LLC All rights reserved No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner The authors, editor, and publisher have made every effort to provide accurate information However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial Research, clinical practice, and government regulations often change the accepted standard in this field When consideration is being given to use of any drug in the clinical setting, the healthcare provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product This is especially important in the case of drugs that are new or seldom used Production Credits Executive Publisher: Christopher Davis Production Director: Amy Rose Senior Acquisitions Editor: Nancy Anastasi Duffy Editorial Assistant: Sara Cameron Senior Production Editor: Daniel Stone Associate Production Editor: Jill Morton Associate Marketing Manager: Katie Hennessy V.P., Manufacturing and Inventory Control: Therese Connell Composition: Dedicated Business Solutions Cover Design: Kate Ternullo Cover Image: © Anna Marynenko/ ShutterStock, Inc Printing and Binding: Malloy Incorporated Cover Printing: Malloy Incorporated Library of Congress Cataloging-in-Publication Data Dx/Rx : sexual dysfunction in men and women / edited by Stanley Zaslau p ; cm Includes bibliographical references and index ISBN-13: 978-0-7637-7196-6 ISBN-10: 0-7637-7196-1 Sexual disorders—Handbooks, manuals, etc I Zaslau, Stanley II Title: Sexual dysfunction in men and women [DNLM: Sexual Dysfunction, Physiological Female Urogenital Diseases— therapy Male Urogenital Diseases—therapy WJ 709 D993 2012] RC556.D95 2012 616.85Ј83—dc22 2010025508 6048 Printed in the United States of America 14 13 12 11 10 10 71966_00_FM_pgs_00i-00x_Zaslau.indd ii 8/31/10 9:35 AM Dedication To our urology residents, past, present, and future, whose interest in and enthusiasm for enhancing their knowledge invigorate us to continue our role as educators 71966_00_FM_pgs_00i-00x_Zaslau.indd iii 8/31/10 9:35 AM 71966_00_FM_pgs_00i-00x_Zaslau.indd iv 8/31/10 9:35 AM Contents Editor’s Preface ix Contributors xi Section 1: Male Sexual Dysfunction 1 Physiology of Erection Aimee Rogers, MD Stanley Zaslau, MD, MBA, FACS Introduction Role of Spinal Cord and Neural Innervation of the Penis Hormonal Control of Sexuality Conclusions Physiology of Ejaculation Hormonal Control of Ejaculation 11 Conclusions 15 References 15 Pathophysiology of Erectile Dysfunction 17 Aimee Rogers, MD Stanley Zaslau, MD, MBA, FACS Introduction Epidemiology Classification Endocrinologic Arteriogenic Vasculogenic Conclusions References 17 17 18 21 22 23 25 25 v 71966_00_FM_pgs_00i-00x_Zaslau.indd v 8/31/10 9:35 AM vi Contents Physical Diagnosis and Testing 27 Aimee E Rogers, MD Stanley Zaslau, MD, MBA, FACS Introduction Initial Evaluation Laboratory Testing Noninvasive Methods of Evaluation Vascular Evaluation Conclusions References Medical Therapies for Erectile Dysfunction 39 Adam Luchey, MD Stanley Zaslau, MD, MBA, FACS Introduction Erectile Dysfunction Conclusions References 39 39 47 48 Surgical Treatments for Erectile Dysfunction 51 Aimee E Rogers, MD Stanley Zaslau, MD, MBA, FACS Introduction Penile Prostheses Vascular Surgery for Erectile Dysfunction Conclusions References 27 27 29 31 34 35 36 51 51 64 64 65 Peyronie’s Disease 69 Adam Luchey, MD Stanley Zaslau, MD, MBA, FACS Introduction Physical Examination Medical Therapy Surgical Therapy Conclusions References 71966_00_FM_pgs_00i-00x_Zaslau.indd vi 69 69 70 72 74 74 8/31/10 9:35 AM vii Contents Section 2: Female Sexual Dysfunction 77 Physiology of Female Sexual Function 79 Chad P Hubsher, MD Adam Luchey, MD Stanley Zaslau, MD, MBA, FACS Introduction Female Sexual Response Cycle Female Sexual Anatomy Female Sexual Response Physiology of Sexual Arousal Conclusions References 79 79 80 87 88 91 92 Classification and Pathogenesis of Female Sexual Dysfunction 95 Chad P Hubsher, MD Aimee Rogers, MD Stanley Zaslau, MD, MBA, FACS Introduction and Classification 95 Etiologies of Female Sexual Dysfunction 99 Conclusions 109 References 109 Physical Diagnosis and Testing 113 Chad P Hubsher, MD Adam Luchey, MD Stanley Zaslau, MD, MBA, FACS Introduction Patient History Medical History Surgical History Obstetric and Gynecologic History Psychiatric History Sexual History Physical Examination Laboratory Tests Special Tests Conclusions References 71966_00_FM_pgs_00i-00x_Zaslau.indd vii 113 113 113 114 115 115 115 119 120 121 121 122 8/31/10 9:35 AM viii Contents 10 Medical Therapies for Female Sexual Dysfunction 125 Chad P Hubsher, MD Adam Luchey, MD Stanley Zaslau, MD, MBA, FACS Introduction Psychotherapeutic Interventions Pharmacological Interventions Conclusions References 11 125 125 130 139 140 Noninvasive Treatments for Female Sexual Dysfunction 145 Chad P Hubsher, MD Aimee Rogers, MD Stanley Zaslau, MD, MBA, FACS Introduction Psychotherapeutic Interventions Conclusions References 145 145 156 156 Appendix I: Female Sexual Function Index 159 Index 165 71966_00_FM_pgs_00i-00x_Zaslau.indd viii 8/31/10 9:35 AM Editor’s Preface It is our belief that sexual dysfunction is a common condition affecting both men and women Many practitioners, particularly in the disciplines of family practice, internal medicine, and urology, may have the opportunity to treat both male and female patients, sometimes even the husband and wife of a family In such instances, sexual dysfunction may be occurring in both partners For that reason, we decided to present information regarding the pathogenesis, diagnosis, and treatment of sexual dysfunction in men and women in the same book The book is well supplemented with tables and timely references Any practitioner who deals with both male and female patients with sexual problems will find this book to be useful Stanley Zaslau Morgantown, West Virginia ix 71966_00_FM_pgs_00i-00x_Zaslau.indd ix 8/31/10 9:35 AM 62 Chapter ■ ■ ■ ■ sites as areas to erode are the lack of distal penile sensation in the patient with a spinal cord injury, diabetes, or someone who has previously undergone external beam irradation Erosion is also possible if an oversized prosthesis is used This can lead to erosion by tissue pressure atrophy and necrosis Erosion can also occur if a patient keeps the prosthesis inflated when they are not using it This can also lead to tissue pressure atrophy and necrosis Erosion of the reservoir into the bladder or into the bowel are extremely rare complications The scrotally placed penile implant pump can also erode This can occur in patients with impaired sensation such as diabetics and patients with spinal cord injury Mechanical Failure and Subsequent Operation ■ True mechanical failures for inflatable penile prostheses include leakage of fluid from various points including: • Tubing leak • Pump leak • Reservoir leak • Cylinder aneurysm ■ While individual components may be at fault, it is the author’s recommendation that the individual component be replaced if the implant was initially placed in the preceding 12 months If the implant has been in place for longer that 12 months, the entire device should be replaced Penile Shortening ■ Penile shortening is likely to occur after placement of a penile prosthesis This can be due to ischemia of corporal and tunica albiginea layers of the corpus cavernosa This is common in patients with ED of many years duration ■ It is important to counsel patients preoperatively about the likelihood of penile shortening after penile prosthesis implantation This will improve patient satisfaction postoperatively 71966_05CH_pgs_051-068_Zaslau.indd 62 8/31/10 9:35 AM Surgical Treatment for Erectile Dysfunction 63 ■ It is possible to perform a ligation of the penile suspensory ligament in an effort to gain additional penile length In the author’s opinion, while this may produce additional penile length, the penis is more floppy and can hang lower because of its lack of ligamentous support Urethral Injury ■ Urethral injury can occur during dilation of the corporal bodies during placement of the prosthesis ■ This injury is likely to be more common in patients who have had prior pelvic external beam irradiation, have diabetes mellitus, or who have suffered a pelvic fracture ■ Care must be taken not to injure the urethra during the procedure For distal urethral injuries, the implant procedure should be abandoned and the patient left with a urinary catheter in place A second procedure can be undertaken after three months For proximal urethral injuries, the urethral injury can be repaired over a urinary catheter While one could consider placement of the penile implant at this time, the authors recommend waiting until the urethral injury has healed and then undertake a second operation at a later date Impaired Sensation ■ Patients who are diabetics, have a history of spinal cord injury, or have received pelvic irradation are at increased risk for loss of penile sensation after placement of a penile implant ■ It is likely that the patient’s underlying disease state resulted in the impaired penile sensation rather than the implant procedure causing this complication ■ In such patients, malleable penile implants are more likely to cause erosion particularly because the patient will not feel the implant In fact, such patients may not realized that erosion has occurred until there is secondary infection present These patients are better served with a three-piece inflatable prosthesis because it can be deflated, which can minimize the risk of erosion 71966_05CH_pgs_051-068_Zaslau.indd 63 8/31/10 9:35 AM 64 Chapter ■ Vascular Surgery for Erectile Dysfunction History ■ The first cases of penile arterial bypass surgery for erectile dysfunction were reported by Michal and colleagues in the early 1970s, using the inferior epigastric artery as the donor vessel.39 ■ Subsequent modifications by Virag and others resulted in a multitude of procedures that used the deep dorsal vein as the recipient vessel.40 ■ Crespo and colleagues presented procedures for revascularization of the cavernosal artery directly by use of the inferior epigastric artery as a donor source.41 ■ Lack of standardized techniques and selection criteria may contribute to the current low popularity of arterial revascularization To date, no single procedure has been universally accepted Indications ■ ■ ■ ■ Vascular surgical procedures, particularly penile arterial revascularization and penile venous surgery, are recommended only for a select group of patients Several series have reported reasonable success for penile arterial reconstructive surgery if performed in young, nonsmoking, healthy men with recently acquired erectile dysfunction secondary to focal arterial occlusion with no evidence of generalized vascular disease.42 According to DePalma and colleagues, only 6–7% of men with vascular erectile dysfunction are candidates for arterial reconstructive surgery.43 Another study performed years later revealed that success rates in older men with diabetes or other evidence of generalized vascular disease were also very low.44 ■ Conclusions ■ Surgical intervention has an important role in the management of patients with ED when systemic and other approaches fail or are contraindicated 71966_05CH_pgs_051-068_Zaslau.indd 64 8/31/10 9:35 AM Surgical Treatment for Erectile Dysfunction 65 ■ ■ Physicians must always consider the mental and manual dexterity of the patient when selecting a malleable versus inflatable prosthesis Physicians must carefully explain to patients and their partners the risks and benefits of penile implant surgery before performing any procedure ■ References 10 11 12 13 Lue TF Erectile dysfunction N Engl J Med 2000;342: 1802 Broderick GA, Lue TF Evaluation and nonsurgical management of erectile dysfunction and premature ejaculation In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:750–787 Morgentaler A Male impotence Lancet 1999;354:1713 Scott FB, Bradley WE, Timm GW Management of erectile impotence: use of implantable penile prostheses Urology 1973;2:80 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Wilson S Penile prostheses at the millennium Contemp Urol 2001;35 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Gross AJ, Sauerwein DH, Kutzenberger J, Ringert RH Penile prostheses in paraplegic men Br J Urology 1996;78: 262 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 71966_05CH_pgs_051-068_Zaslau.indd 65 8/31/10 9:35 AM 66 Chapter 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Khoudary KP, Morgentaler A Design considerations in penile prostheses: the American Medical Systems product line J Long Term Eff Med Implants 1997;7:55 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Quesada ET, Light JK The AMS 700 inflatable penile prosthesis: long-term experience with the controlled expansion cylinder J Urol 1993;149:46 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Jarow JP Risk factors for penile prosthetic infection J Urol 1996;156:402 Wilson SK, Carson CC, Cleves MA, Delk JR Quantifying risks of penile prosthesis infection with elevated glycosylated hemoglobin J Urol 1998;159:1537 Dos Reis JM, Glina S, Da Silva MF, Furlan V Penile prosthesis surgery with the patient under local regional anesthesia J Urol 1993;150:1179 D’Amico DF, Parimbelli P, Ruffolo C Antibiotic prophylaxis in clean surgery: breast surgery and hernia repair J Chemother 2001;13(Spec 1):108 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 71966_05CH_pgs_051-068_Zaslau.indd 66 8/31/10 9:35 AM Surgical Treatment for Erectile Dysfunction 67 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Lazarou S Surgical treatment of erectile dysfunction UpToDate 2009 Jarow JP Risk factors for penile prosthetic infection J Urol 1996;156:402 Wilson SK, Delk JR 2nd Inflatable penile implant infection: predisposing factors and treatment suggestions J Urol 1995;153:659 Montague DK: Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell–Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Abouassaly R, Montague DK, Angermeier KW Antibioticcoated medical devices: with an emphasis on inflatable penile prostheses Asian J Androl 2004;6:249–257 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Montague DK Prosthetic surgery for erectile dysfunction In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:788–801 Mulcahy JJ Long-term experience with salvage of infected penile implants J Urol 2000;163:481–482 Montague DK, Angermeier KW Penile prosthesis implantation Urol Clin North America 2001;28:355 Michal V, Kramar R, Pospichal J, Hejhal L Direct arterial anastomosis to the cavernous body in the treatment of erectile impotence Rozhl Chir 1973;52:587–592 Virag R, Bennett AH Arterial and venous surgery for vasculogenic impotence: a combined French and American experience J Urol 1986;135:699–702 Crespo EL, Soltanik E, Bove D, Farrell G Treatment of vasculogenic sexual impotence by revascularization of cavernous and/or dorsal arteries using microvascular techniques Urology 1982;20:271–279 71966_05CH_pgs_051-068_Zaslau.indd 67 8/31/10 9:35 AM 68 Chapter 42 43 44 Goldstein I Overview of types and results of vascular surgical procedures for impotence Cardiovasc Interv Radiol 1988;11:240 DePalma RG, Olding M, Yu GW, et al Vascular interventions for impotence: lessons learned J Vasc Surg 1995;21: 576 Vardi Y, Gruenwald I, Gedalia U, et al Evaluation of penile revascularization for erectile dysfunction: a 10-year followup Int J Impot Res 2004;16:181 71966_05CH_pgs_051-068_Zaslau.indd 68 8/31/10 9:35 AM C H A P T E R Peyronie’s Disease Adam Luchey, MD Ⅲ Stanley Zaslau, MD, MBA, FACS ■ Introduction ■ ■ ■ ■ ■ Named after Franỗois Gigot de la Peyronie in 1741, Peyronies disease (PD), a benign condition, is characterized by a palpable plaque and curvature of the penis when erect Lindsay et al published the results of a 35-year study that showed a prevalence of 0.4% and the average age of onset at 53 years.1 However, when studied in autopsies, Smith noted the prevalence of plaques to be 22 of 100 men More recently, a review by Jalkut et al stated that the increasing number of men presenting today with Peyronie’s disease can be attributed to the role of phosphodiesterase inhibitors in treatment for erectile dysfunction Thus, an underlying ED may be responsible for the development of Peyronie’s disease Although no specific cause can be attributed to Peyronie’s disease, sexual trauma is strongly suspected • Trauma to the tunica albuginea allows release of transforming growth factor, activating reactive oxygen species, which allows collagen deposits and calcification of the plaque that causes the deformity.3 ■ Physical Examination ■ ■ Peyronie’s disease is divided into two phases, the acute and the chronic phase The acute phase is characterized by: • Painful erections • Nodule formation • Change in curvature of erection (up to the first 18 months) 69 71966_06CH_pgs_069-076_Zaslau.indd 69 8/31/10 9:34 AM 70 Chapter ■ ■ ■ ■ ■ ■ ■ ■ The chronic phase is characterized by: • Stable nodule and deformity • Relief of discomfort4,5 Peyronie’s disease can cause erectile dysfunction in up to 30–50% of cases and can prevent the patient from engaging in sexual intercourse Photographs of the erections are helpful, especially for following changes with treatment and planning any operative management The majority of the plaques are located on the dorsal or lateral sides of the penis When talking with patients, the practitioner should inquire about other risk factors that may cause erectile dysfunction, such as: • Diabetes • Smoking • Hyperlipidemia • Hypertension • Coronary artery disease Some believe there is an association between Peyronie’s disease and Dupuytren’s contractures, which should also be evaluated on physical exam Examining the penis in an outstretched position can help identify the extent of the plaques Ultrasound can help identify any calcification and can aid in tracking progression and/or response to treatment ■ Medical Therapy Vitamin E ■ Vitamin E is an antioxidant, which means it inhibits oxidation by free radicals (Table 6.1) ■ However, it has a few side effects: • Treatment can increase the likelihood of heart failure • Has anticoagulative effects ■ Recent studies fail to show significant clinical benefit.8 ■ This agent is given in divided doses of 800–1000 units per day Typically Vitamin E is used for less than six months 71966_06CH_pgs_069-076_Zaslau.indd 70 8/31/10 9:34 AM 71966_06CH_pgs_069-076_Zaslau.indd 71 Small, noncontrolled, unblinded shown benefit of improving curvature and decreasing plaque size12 Regulated immune response through TGF-B decreasing fibrinogenesis13 Showed promise when compared to tamoxifen Decrease in plaque volume and possible decrease in Only benefits acute phase Topical verapamil not curvature deformity through inhibiting exocytosis of recommended.17 collagen, fibronectin, and glycosaminoglycans (increase collagenase activity)14 Hypothesize plaque lysis through inflammatory macrophages Colchicine Tamoxifen Carnitine Intralesional Verapamil ESWT No improvement in curvature, plaque size, or sexual function.18,19 Not recommended when compared to placebo16 Alopecia, no difference between tamoxifen and placebo15 Check periodic CBC (can lower blood cell counts), diarrhea Expensive, GI upset Other studies have shown no benefit of correcting deformity; not recommended.9,10,11 Possibly decrease fibrinogenesis through altering serotonin levels4 Aminobenzoate Potassium Recent studies fail to show benefit.6,7 Treatment can potentiate heart failure and anticoagulative effects Cons Antioxidant, scavenger of free radicals, few side effects Pros Treatments for Peyronie’s Disease Vitamin E Table 6.1 Peyronie’s Disease 71 8/31/10 9:34 AM 72 Chapter Dosage ■ Vitamin E: Divided doses of 800–1000 units per day ■ Aminobenzoate Potassium: 12 g/day in 4–6 divided doses6 ■ Colchicine: 0.6 mg–1.2 mg daily for first week to 2.4 mg daily for three months in divided doses ■ Tamoxifen: 20 mg twice daily ■ Carnitine: gram twice daily ■ Intralesional Verapamil: 12 injections (10 mg/ml) per day for two to four weeks Abern and Levine studied intralesional steroids, which showed no objective benefit, and collagenase, which showed a possible benefit in plaque width and curvature; further studies are ongoing The same researchers also showed promising results from taking combination intralesional verapamil with traction and oral pentoxifylline and L-arginine.11 ■ Surgical Therapy ■ This procedure is not appropriate during the acute phase (Ͻ years, painful erections) when the plaque is still changing and not mature Three procedures are considered to be commonly performed depending on the degree and location of the plaque These are: Nesbitt procedure Plaque excision and graft interposition Penile prosthesis placement and orthoplasty Nesbit Procedure Nesbit procedure was first described in 1965 for correction of congenital curvature.20 When performing the Nesbit procedure, an elliptical incision is made into the tunica albuginea opposite that from the plaque in order to straighten the curvature ■ Patients are told pre-operatively that they will experience penile shortening on average of 0.5 cm but values greater than this have been reported In addition, details on loss of sensation, hematoma, and urethral injury have to be included 71966_06CH_pgs_069-076_Zaslau.indd 72 8/31/10 9:34 AM Peyronie’s Disease 73 ■ ■ Akkus et al., which published recommendations from 10 experts, stated that the Nesbit procedure was the treatment of choice with the least risk of postoperative erectile dysfunction for a stable deformity.21 Through modification of the procedure, Rolle et al were able to achieve a statistical improvement in erectile dysfunction through a modified corporoplasty that enabled them to excise the fibrosed tunica albuginea only after the correct position was determined in real time without lengthening the operation This was proven in both acquired and congenital penile curvature.22 Plaque Excision and Graft Interposition ■ In general, graft material (buccal, saphenous vein, tunica vaginalis, fascia lata, rectus fascia, cadaveric, and bovine pericardium) has less of a risk of penile shortening than other surgical procedure but the risk of erectile dysfunction is greater ■ Buccal mucosa has been shown to have no shrinkage or change in elasticity and Liu et al achieved complete straightening in 21 of 24 patients followed for 0.5–7 years with minimal loss of length.23 ■ In a retrospective analysis of 11 patients undergoing dermal grafting, were encouraged to achieve erections after two weeks and sexual intercourse after six weeks.24 ■ In a head to head comparison between cadaveric pericardium and dermal grafts, Chun and McGregor et al showed that cadaveric pericardial grafts are equal to dermal grafts with the added benefit of commercial availability without the need for harvesting.25 Penile Prosthesis Placement with Orthoplasty Prosthesis involvement for Peyronie’s is best suited for the elderly male with significant curvature as well as severe erectile dysfunction, and for this it is considered the firstline of treatment.26 ■ Older prostheses did not allow modeling because their length did not achieve the rigidity needed to correct 71966_06CH_pgs_069-076_Zaslau.indd 73 8/31/10 9:34 AM 74 Chapter curvature With advances in penile prostheses their applicability in Peyronie’s grew Ghanem et al studied 20 men who had malleable penile prosthesis placed, all of which failed intracavernous injections They reported straightening of the penile shaft in all cases and all but two were satisfied at one year post-op.27 ■ Carson and colleagues studies 30 men, all with their duration of deformity greater than 12 months who were able to achieve penile straightening with a functional implant and modeling in 28 patients; the remaining required plaque incision.28 It has been known that modeling over an implant lends to an increase in intra-operative urethral injury compared to implantation of prosthesis by itself.29 ■ There is no one perfect operation for chronic Peyronie’s disease The physician must take into account the underlying erectile function, or lack thereof, and the risk of penile shortening when determining their approach As always, surgeon experience is critical to patient outcome ■ Conclusions ■ ■ ■ ■ Although no specific cause of Peyronie’s disease is fully known, sexual trauma is strongly suspected Peyronie’s disease can cause ED and can prevent the patient from engaging in sexual intercourse Medical and surgical therapies are available to treat Peryonie’s disease Treatment must be individualized to the patient’s degree of curvature, location of curvature, and presence of underlying ED Treatment is currently evolving and continued research in this area is ongoing ■ References Lindsay MB, Schain DM, Grambasch P The incidence of Peyronie’s disease in Rochester, Minnesota, 1950 through 1984 J Urol 1991;146:1007–1009 Smith BH Subclinical Peyronie’s disease Am J Clin Pathol 1969;52:385–390 Jalkut M, Gonzalez-Cadavid N, Rajfer J Peyronie’s disease: a review Rev Urol 2003 Summer;5(3):142–148 71966_06CH_pgs_069-076_Zaslau.indd 74 8/31/10 9:34 AM Peyronie’s Disease 10 11 12 13 14 15 16 17 75 Hellstrom WJ Medical management of Peyronie’s disease J Androl 2009;30:397–405 Gelbard MK, Dorey F, James K The natural history of Peyronie’s disease J Urol 1990;149:53–55 Hasche-Klunder R Treatment of Peyronie’s disease with para-aminobenzoacidic potassium (POTABA) Urologe A 1978;17:224–227 Pryor JP, Farrell CF Controlled clinical trial of vitamin E in Peyronie’s disease Prog Reprod Biol 1983;9:41–45 Broderick GA, Lue TF Evaluation and nonsurgical management of erectile dysfunction and premature ejaculation In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds Campbell-Walsh Urology 9th ed Philadelphia, PA: Saunders Elsevier Company; 2007:818–838 Hasche-Klunder R Treatment of Peyronie’s disease with para-aminobenzoacidic potassium (POTABA) Urologe A 1978 Jul;17(4):224–227 Weidner W, Hauch EW, Schnitker J Peyronie’s disease study group of andrological group of german urologists Potassium paraaminobenzoate (Potaba) in the treatment of Peyronie’s disease: a prospective, placebo-controlled, randomized study Eur Urol 2005;47:530–536 Abern M, Levine L Peyronie’s disease: evaluation and review of nonsurgical therapy TSWJ 2009 Jul 27;9:665–675 Akkus E, Carrier S, Rehman J, et al Is colchicine effective in Peyronie’s disease? 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